Gastrointestinal Procedures: Balloon Enteroscopy
Guest: Dr. Mark DeLegge – Gastroenterology-Hepatology
Host: Dr. Linda Austin – Psychiatry
Dr. Linda Austin: I am Dr. Linda Austin. I am interviewing Dr. Mark DeLegge who is Director of the Digestive Disease Center here at the Medical University of South Carolina. Dr. DeLegge, let’s talk about a procedure called balloon enteroscopy. Can you describe what that is?
Dr. Mark DeLegge: Sure. We have talked in the past about endoscopy which basically is looking into, for us, the gastrointestinal tract. There is this funny word, enteroscopy; e, n, t, e, r, o, s, c, o, p, y. Essentially what that means is looking into the small intestine. You know that once you get beyond the stomach, your small intestine has three parts, the duodenum, the jejunum and the ileum. A whole host of diseases can hide out in the small intestine. It is not uncommon for a referral to come in for bleeding, meaning that the patient has bright red blood or dark stool, and we do a colonoscopy, look in their colon, nothing there, we do an upper endoscopy, we look in their esophagus, their stomach and their duodenum, nothing there. We ask ourselves, should we look into their small intestine? Could there be a part of the gut here that we have not seen that could be bleeding? Obviously, the answer is, yes.
For years, the only real device we had for looking into your small intestine was called an enteroscope. Basically, it was an endoscope that was a little bit longer, so we could look down through your duodenum and then maybe get through the first one third of your jejunum. So, there is all this small intestine that we could never see. So, when we talk about the word enteroscopy, we are really talking about looking with an endoscope into the small intestine.
Dr. Linda Austin: People certainly are familiar with things like reflux disease or stomach ulcers at the upper end of the GI system, and colonoscopy is virtually a household word, and most people have known somebody who has had colon cancer. It seems to me that the small intestine, though, which is the part in between, does not get as much attention. Is that because the illnesses there are less common, or just because we have not had the means for investigating that area?
Dr. Mark DeLegge: It is both. If you look at diseases of the esophagus or stomach or colon, compared to the small intestine, the small intestine has fewer incidences of diseases. There is a whole host of things that can happen, but usually in smaller numbers. Still, it is like the black box, meaning, until we have the instrumentation to actually look there, there may be symptoms, like chronic abdominal pain, that we are ascribing to, perhaps, the fact that the patient has irritable bowel syndrome and cramping when, in fact, there may actually be something going on in the small intestine. So, I think you hit the nail on the head. As we start to develop the instrumentation for looking deep into the small intestine, we are going to find out a lot about a lot of diseases.
Dr. Linda Austin: And what are some of the common diseases of the small intestine, now that you pick up with balloon enteroscopy?
Dr. Mark DeLegge: We pick up diseases such as tumors of the small intestine. Just like you can get a cancer of the stomach or esophagus, you can get a cancer of the small intestine. We pick up ulcerations. People do not think about ulcers being in their small intestine but, in fact, they are not that uncommon. Usually, or often, it can be from medication. If you hear about things like aspirin causing an ulcer in the stomach, yeah, that happens and we see that. But, in fact, aspirin will travel downstream from there and it can cause an ulceration in the small intestine. So, ulcers or other bleeding lesions, what I mean by that is funny blood vessels that are in the small intestine that just kind of ooze blood over time and people may have this chronic anemia where their blood counts are always low. Or, perhaps, you have a sudden spurt of blood. That may come from a lesion in the small intestine that can just be an abnormal growth of tissue. Or, the polyps that we see in the colon, different types of polyps, not the same type, can occur actually in the small intestine.
Dr. Linda Austin: So, when you do balloon enteroscopies, about what percent of the time do you actually find some kind of pathology or disease process going on in the small intestine that accounts for what you are looking for?
Dr. Mark DeLegge: I would say, at this particular point, it is somewhere between 40 to 50 percent that we are actually finding something. Remember, I was talking to you previously about enteroscopy, which we got down about a third of the way into the jejunum, which is not very far? This new balloon device, what it is, essentially, is a sheath that goes over our normal enteroscope and it has a balloon on it. What you are able to do is push the enteroscope and the sheath into the small intestine, blow the balloon up and by doing that, you are able to essentially sleeve the small intestine over the enteroscope. Imagine having a hose out in the middle of the yard and you have a long tube of cotton over the top of it and you start to sleeve the cotton tube over the garden hose, you, pretty much, would be able to see the whole cotton sleeve. That is essentially what you are doing with the balloon enteroscope. You are sleeving the small bowel over the enteroscope so you can get much farther down into the small intestine. With that, there is a greater likelihood of picking up abnormalities.
Dr. Linda Austin: So, just to be a little concrete about it, it reminds me a little bit of when you put a big safely pin on the end of a cord that you are trying to pass through the top of your pajama pants, where the cord comes out. Is that right, that it allows you to sort of grip and go through?
Dr. Mark DeLegge: Absolutely. That is exactly what it is, essentially, grabbing the small intestine and pulling it backwards over the enteroscope. Remember, again, this is a procedure where you are sedated. We are not doing this while you are awake. We give you medication so that you do not remember anything and you do not feel anything. This has really been a tremendous advancement in gastroenterology.
Dr. Linda Austin: How long has this procedure been out and available?
Dr. Mark DeLegge: The procedure itself has been out for about a year. We have had it here, at MUSC, for about four to five months. Frankly, our experience with it so far has been very good. As you can imagine, with any new technology, the people doing the procedure have to gain experience with it and have to be good at it. Fortunately, before we ever started balloon enteroscopy, we did a tremendous amount of just enteroscopy here, at MUSC. So, we already had some significant experience, and moving onto to this new device was not really a big ladder for us to climb. Right now, I would say, we are pretty darned good at using balloon enteroscopy to treat diseases of the esophagus, we will say, a bleeding lesion that you could put a little catheter through and cauterize, like you are basically cauterizing a wart, or, perhaps, taking a biopsy, or even going through and finding an area that, perhaps, has some scar tissue and being able to pass a balloon through there, through your enteroscope, and open it up to dilate the area.
Dr. Linda Austin: It speaks, though, to how fantastic it is that we have a Digestive Disease Center here where we have enough volume, enough patients, to be able to support the technology and the training process to use cutting edge, state of the art, technology.
Dr. Mark DeLegge: We are really focused at the Digestive Disease Center, at MUSC, on innovation to achieve excellence. What I mean by that is, not everything that comes out from industry works well, a new device, a new procedure, a new way to do something, but we evaluate everything very closely and very quickly to see what it is that we can offer our patients that will maximize their outcomes and keep them safe.
Dr. Linda Austin: Thanks so much.
Dr. Mark DeLegge: You are welcome.
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